Introduction

Sample Tools

Transition consists of joint planning with young adults to foster development of self-care skills and active participation in decision-making. It also consists ensuring a smooth transfer to adult-centered care with current medical information. The Six Core Elements of Health Care Transition 2.0 define the basic components of health care transition support and the corresponding sample tools provide tested means for integrating young adults into adult care. These transition resources are consistent with the AAP/AAFP/ACP Clinical Report on Transition.

Recognizing and responding to the diversity among young adults and their families is essential to the transition process. This diversity may include but is not limited to differences in culture, race, ethnicity, languages spoken, intellectual abilities, gender, sexual orientation, and age. Since implementation of the Six Core Elements depends so much on patient and provider communication, health plans and practices should use appropriate oral and written communications, including interpretation and translation services and health literacy supports as needed.1 In addition, engaging young adult and parents/caregivers from various cultural backgrounds in the development and evaluation of a transition quality improvement process is important.2

To implement the Six Core Elements, a quality improvement approach is recommended. Plan-do-study-act (PDSA) cycles provide a useful way to incrementally adopt the Six Core Elements as a standard part of care for young adult and their families.3 The process begins with the creation of a collaborative pediatric and adult team that could include physicians, nurse practitioners, physician assistants, nurses, social workers, care coordinators, medical assistants, administrative staff, IT staff, and young adult/young adults and families. Leadership support from the practice, plan, or academic department is critical as well. Oftentimes, practices decide to begin with a subset of young adult in order to pilot the pediatric and adult delivery system changes needed for transition. Sample tools that can be customized for use in primary and specialty care are available in this package and on www.GotTransition.org.